The safety and efficacy of thoracoscopic lobectomy have been demonstrated in several large studies, comparable to open lobectomy (1-3). VATS lobectomy has been shown to be associated with less morbidity (4-7), at least equivalent mortality (4,8,9), shorter hospital stays (4-8), improved functional outcomes (10-12), and less costs (13-15) compared with an open approach. Perhaps most important, minimally invasive lobectomy is oncologically equivalent (1,4,8,9,16,17), at a minimum, to lobectomy through open thoracotomy. A direct comparison with open lobectomy remains lacking, though, and the concept of a prospective randomized trial comparing the open and VATS approaches has been considered repeatedly. However, the recognized advantages of a thoracoscopic approach among dedicated thoracic surgeons have likely eroded any clinical equipoise needed for such a trial. Indeed, these advantages are not lost on practicing thoracic surgeons. Approximately 50% of lobectomies registered in the Society of Thoracic Surgeons General Thoracic Database are completed via a thoracoscopic approach (18), and the percentage continues to increase.
Current frontiers in thoracoscopic surgery now include chest wall resection and reconstruction, muscle flap transposition, sleeve resection, and the use of uniportal techniques. In the years ahead, we may expect advances in these areas, along with further refinement of established techniques in thoracoscopic surgery.